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Acta Chirurgica Belgica

ISSN: 0001-5458 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/tacb20

Faecal impaction causing bilateral pelvic venousthrombosis

Maxime Dewulf, Yves Blomme & Cedric Coucke

To cite this article: Maxime Dewulf, Yves Blomme & Cedric Coucke (2017): Faecalimpaction causing bilateral pelvic venous thrombosis, Acta Chirurgica Belgica, DOI:10.1080/00015458.2017.1310482

To link to this article: http://dx.doi.org/10.1080/00015458.2017.1310482

Published online: 11 Apr 2017.

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CASE REPORT

Faecal impaction causing bilateral pelvic venous thrombosis

Maxime Dewulf , Yves Blomme and Cedric Coucke

Department of Vascular Surgery, AZ Sint Lucas, Ghent, Belgium

ABSTRACTIntroduction: We present a first description of faecal impaction (FI) causing occlusion of thepelvic venous system, resulting in a bilateral thrombosis of the external iliac vein.Patients and methods: Our 76-year-old female patient was admitted with gradual swellingof both legs. Clinical evaluation revealed a painless abdominal distension and marked bilat-eral edema of the legs. A computed tomography (CT) scan showed gross dilatation of thecolon and rectum, with FI. A short bilateral occlusion of the external iliac vein was seen, withthrombus in both pelvic veins. Doppler ultrasonography confirmed a thrombosis of theexternal iliac vein and common femoral vein on both sides.Results: A conservative treatment consisting of manual evacuation, enema, laxatives andsystemic anticoagulation was successfully applied.Conclusions: FI represents a common – yet preventable – health problem, mainly in theelderly. This case illustrates a rare complication of FI if left untreated.

Abbreviations: CT: Computed Tomography; FI: Faecal Impaction; IVCS: Iliac VeinCompression Syndrome; NOAC: Novel Oral AntiCoagulant; PEGþ E: PolyEthylene Glycol 3350þ Electrolytes; VKA: Vitamin K Antagonist; PTS: Post-Thrombotic Syndrome

ARTICLE HISTORYReceived 8 November 2016Accepted 19 March 2017

KEYWORDSFaecal impaction; venousthrombosis; iliac vein

Introduction

We present a case of faecal impaction (FI) causingbilateral occlusion of the pelvic venous system,resulting in a thrombosis of the external iliac veinand the common femoral vein. This is the firstdescription of this rare complication of FI occurringon both sides in an adult patient, in which a con-servative treatment was successfully applied.

Case report

A female, Caucasian patient, 76 years of age, wasadmitted to our emergency department withsymptoms of gradual swelling of both legs for thepast 5 d.

In her medical history we withhold a long-stand-ing problem of severe chronic constipation, forwhich she was repeatedly seen at our hospital byher treating gastroenterologist. A full diagnosticwork-up was performed only six months beforepresentation, including a total colonoscopy. At thattime there were no mucosal deformities. Nineyears before our patient underwent breast-conserving surgery, postoperative radiotherapyand an axillary lymph node dissection because ofan invasive ductal carcinoma of the right breast.

With a quiet oncological follow-up ever since, heractual medical therapy consisted solely of osmoticlaxative agents.

Upon clinical evaluation our mildly obesepatient presented with a marked abdominal dis-tension, hypoperistaltis, and diffuse pain duringpalpation. In the left lower quadrant and in thesuprapubic area a hard mass was palpable. Therewas no rebound tenderness. Digital rectal examin-ation showed a normal sfincter tone, with hardfaecal masses present in the distal rectum.Furthermore, a bilateral swelling of her entire legon both sides with a marked pitting edema wasseen, with full complement of arterial pulsations,and no signs of infection. The buttock was notparticularly swollen, and clinically there were nocollateral veins visualised. There were no inguinallymph nodes palpable. Our patient did not have afever, and only a mild hypotension (systolic bloodpressure 100mmHg) and tachycardia (90/min) waspresent.

A computed tomography (CT) scan was per-formed, revealing a gross dilatation of the colonand rectum, with a giant rectal faecaloma. A shortbilateral occlusion of the external iliac vein wasseen, with thrombus in both pelvic veins more

CONTACT Dewulf Maxime dewulfmaxime@gmail.com Department of Vascular Surgery, AZ Sint Lucas, Groenebriel 1, 9000 Ghent, Belgium� 2017 The Royal Belgian Society for Surgery

ACTA CHIRURGICA BELGICA, 2017http://dx.doi.org/10.1080/00015458.2017.1310482

distally (Figure 1), up to the level of the commonfemoral vein (Figure 2). There was no hydroneph-rosis. This was confirmed by duplex ultrasonog-raphy, showing a bilateral thrombosis of theexternal iliac vein and common femoral vein. Uponultrasound, there were some collateral veins visual-ised in the upper thigh.

A diagnosis of a giant rectal faecaloma wasmade, as the cause of a bilateral occlusion of theexternal iliac vein, complicated by venous throm-bosis of the pelvic and femoral veins on bothsides.

A conservative treatment consisting of manualevacuation, repeated enema and high-doseosmotic and stimulant laxatives resulted in anevacuation of gross amounts of stool and a grad-ual decompression of the abdomen. The adminis-tration of subcutaneous low-molecular weightheparin (LMWH) was initiated and the therapy wasswitched to an oral Vitamin K antagonist (VKA)after two weeks. Further hospitalisation remaineduneventful, and our patient went home 15 d afteradmission. The discharge medication consistedof an oral VKA and polyethylene glycol 3350 pluselectrolytes (PEGþ E) in moderate doses.Compression therapy with bandages was appliedduring the first three months of treatment.Preventive lifestyle measures as adequate mobilisa-tion and increased daily water and fibre intakewere strongly recommended.

Further follow-up was organised, with ultrasono-graphic evaluation three and six months after dis-charge. A full echographic venous recanalisationwas seen after three months, with mild symptomsof heaviness and edema remaining after sixmonths. The treatment with an oral VKA wasstopped after three months of follow-up, and atthat time the compression therapy was switched

to class II elastic compression stockings. To date,patient generally is doing well, yet her complaintsof heaviness and edema in both legs, and herchronic constipation persist.

Discussion

FI represents a major health problem that canoccur in all age groups, with the paediatric andgeriatric population mainly at risk. Depending onthe setting, the prevalence of FI in the elderlyvaries from 5 to 8.8% [1], and up to 50% of theinstitutionalised geriatric patients develop FI in thecourse of one year [2].

Hussain et al. [1] identified heart disease, bedrest, diabetes, malignancy and neurological dis-order as the main risk factors for the developmentof FI. In this case, none of those were present. Yet,a megacolon and megarectum – both beingimportant anatomic risk factors for FI – are. In ourpatient a diagnosis of idiopathic megacolon andmegarectum can be made, as the long-standingproblem of intestinal dilatation (and associatedconstipation) occurs in the absence of an organiccause [3,4].

Despite the fact that FI in most cases is a pre-ventable disease, it remains associated with a sig-nificant morbidity and mortality, and has majorsocio-economic consequences [1,2]. In a systematicreview, Serrano Falcon et al. recently presented aclassification of the medical complications associ-ated with FI [2]. They propose a subdivision intothree groups, with complications secondary to theeffect of a faecaloma on the intestinal wall and onthe intestinal lumen as the most frequent (73.4%and 14%). Faecaloma affecting adjacent structures

Figure 2. CT scan revealing thrombus up to the commonfemoral vein (arrow).

Figure 1. CT scan showing bilateral occlusion of the externaliliac vein (arrows).

2 M. DEWULF ET AL.

was less frequently reported (12.6%). This lastgroup mainly comprises compression of the urin-ary tract, responsible for 8.5% of the reported com-plications; whereas effects of FI on adjacentvascular or nervous structures were rather anecdot-ical (1.26%). Only a handful papers report pelvicvenous compression due to a rectal faecaloma[3–6]. Because of anatomical considerations, theleft iliac vein seems the most vulnerable to com-pression [3,4]. A recent communication byNaramore et al. (2015) reported a bilateral com-pression of the pelvic veins secondary to FI in apaediatric patient [5]. Two reports even illustratedcompression of the inferior cava vein secondary toa giant intra-abdominal faecal mass [4,6].

In only one of the above, unilateral venous com-pression had led to a deep venous thrombosis(DVT) of the external iliac vein on the left side.Recent prospective data from asymptomaticpatients with a CT-graphic diagnosis of iliac veincompression syndrome (IVCS), or Cockett’s syn-drome, indeed show a low incidence of DVT [7]. Inonly 6 of the 500 included patients (with compres-sion of the iliac vein) a DVT occurred during a fol-low-up of 12 months. A compression of the iliacvein of more than 50% appeared to be the onlyindependent risk factor significantly increasing therisk of DVT. This is probably why a bilateral DVT ofthe iliac vein complicating venous compression byfaecaloma is rare, and remained unreported so far.

In our patient a conservative treatment wasapplied. An anticoagulant treatment with LMWHand an oral VKA was given for three months, andthe FI, being the underlying cause of the venousocclusion, was successfully treated without surgicalintervention. Compression stockings were advisedad vitam.

In case of proximal DVT associated with transi-ent risk factors (in this case the rectal faecaloma),both the American College of Chest Physicians(2016) and European Society of Cardiology (2014)guidelines advise an anticoagulant treatment forthree months [8,9]. As there is growing evidencethat the use of novel oral anticoagulants (NOACs)results in a better adherence to therapy and anoverall reduction of recurrence without increasingthe risk of bleeding, current guidelines recommendthe use of NOACs over an oral VKA [8]. Surely, inour 76-year-old patient a NOAC – without theneed for anticoagulation monitoring and dietaryrecommendations – could have offered someadvantages over a traditional VKA.

Compression therapy remains the golden stand-ard in case of post-thrombotic chronic venous

insufficiency [10]. However, there is growing evi-dence that endovascular treatment provides a clearbenefit in patients with iliocaval obstruction whohave severe symptoms of post-thrombotic syn-drome (PTS) despite adequate compression ther-apy [9,10]. Rather surprisingly, there was a fullvenous recanalisation after three months. Asduplex ultrasound showed no evidence for residualiliocaval venous obstruction, and our patient onlyhad mild symptoms remaining after six months oftreatment, a further endovascular treatment wasnot proposed.

Disclosure statement

The authors report no conflicts of interest. The authorsalone are responsible for the content and writing of thisarticle.

ORCID

Maxime Dewulf http://orcid.org/0000-0002-1945-5481

References

[1] Hussain Z, Whitehead D, Lacy B. Fecal impaction.Curr Gastroenterol Rep. 2014;16:404.

[2] Serrano Falcon B, Barcelo Lopez M, Mateos Munoz B,et al. Fecal impaction: a systematic review of itsmedical complications. BMC Geriatrics. 2016;16:4.

[3] Nguyen H, Simpson R, Kennedy M, et al. Idiopathicmegacolon causing iliac vein occlusion and hydro-nephrosis. Aust NZ J Surg. 2000;70:539–542.

[4] Alvarez C, Hernandez M, Quintano A. Clinical chal-lenges and images in GI: image 2: deep venousthrombosis due to idiopathic megarectum and giantfecaloma. Gastroenterology. 2006;131:702–703.

[5] Naramore S, Aziz F, Alexander C, et al. Fecal impac-tion causing pelvic venous compression and edema.Pediatr Rep. 2015;7:5999.

[6] Scott M. Idiopathic megacolon presenting with fatalinferior vena caval obstruction and colonic perfor-ation. Case report. Acta Chir Scand. 1988;154:605–607.

[7] Wu M, Luo X, Zhang F. Incidence and risk factors ofdeep venous thrombosis in asymptomatic iliac veincompression: a prospective cohort study. Chin MedJ. 2016;129:2149–2152.

[8] Kearon C, Akl E, Ornelas J, et al. Antithrombotic ther-apy for VTE disease: CHEST guideline and expertpanel report. Chest. 2016;149:315–352.

[9] Yin M, Shi H, Ye K, et al. Clinical assessment ofendovascular stenting compared with compressiontherapy alone in post-thrombotic patients with ilio-femoral obstruction. Eur J Vasc Endovasc Surg.2015;50:101–107.

[10] Mahnken A, Thomson K, de Haan M, et al. CIRSEstandards of practice guidelines on iliocaval stenting.Cardiovasc Intervent Radiol. 2014;37:889–897.

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